Aviation safety investigations & reports

Loss of control and collision with terrain involving Cessna 172, VH-EWE, near Moorabbin Airport, Victoria, on 8 June 2018

Investigation number:
AO-2018-048
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At about 1710 on 8 June 2018, the pilot of a Cessna Aircraft Company 172S, registered VH-EWE, was returning to Moorabbin Airport, Victoria, following a one-hour private flight. While on final approach, and shortly after receiving clearance to land, the pilot transmitted ‘we’ve got engine failure’. Shortly after, witnesses observed the aircraft’s left wing and nose drop, consistent with an aerodynamic stall. The aircraft collided with terrain in a residential street about 680 m from the airport. The pilot was fatally injured and a post-impact fuel-fed fire destroyed the aircraft.

There was minor damage to one residence and a vehicle, there were no injuries to persons on the ground.

What the ATSB found

The ATSB examined the aircraft’s engine, its components and fuel system, but was unable to determine the reason for the reported engine power loss. The investigation also found that when control of the aircraft was lost, there was insufficient height to recover.

Safety message

The loss of engine power while on final approach presents a scenario where there may be limited forced landing options, especially when there is insufficient height to glide to the airport. This is particularly relevant where the approach is over built-up areas, such as at Moorabbin Airport. The ATSB publication, Avoidable Accidents No. 3 - Managing partial power loss after take-off in single-engine aircraft provides guidance that is also applicable to an engine failure occurring at low-level during an approach. Taking positive action and ensuring that control is maintained has a much better survivability potential than when control of the aircraft is lost. In addition, using the aircraft structure and surroundings to absorb energy and decelerate the aircraft can assist in minimising injury.

Having a clear, defined emergency plan prior to the critical stages of the flight, such as approach, removes indecision and reduces pressure on the pilot while in a high stress situation. Further, flying the approach as per manufacturer and airport procedures places the aircraft in the optimum configuration and position.

Proficiency in in-flight emergencies can be improved by regularly practicing these emergencies. The United States Federal Aviation Administration safety briefing September/October 2010 described this as ‘imbuing the quantity of all your flying, however limited, with quality’.

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The occurrence

Context

Safety analysis

Findings

Sources and submissions

Preliminary report

Preliminary report published: 18 July 2018

On 8 June 2018, a Cessna Aircraft Company C172S, registered VH-EWE (EWE), was being operated on a private flight from, and intending to return to, Moorabbin Airport, Victoria. The flight was the first one after scheduled maintenance. The pilot, an employee of the maintenance organisation, was the sole occupant.

The aircraft departed Moorabbin Airport at about 1600 Eastern Standard Time.[1] Recorded Air Traffic Control (ATC) data showed that the aircraft climbed to an altitude of 3,000 ft above mean sea level and tracked towards Tyabb, Victoria.

At 1707, the pilot reported to Moorabbin ATC that EWE was at reporting point GMH at 1,500 ft, inbound to Moorabbin. ATC instructed the pilot to join base for runway 35 Right (R). At 1710, ATC requested EWE change runways to 35 Left (L), due to the number of aircraft tracking for 35R. The pilot accepted the runway change and at 1712, EWE was cleared to land on runway 35L. At 1713, the pilot of EWE broadcast a MAYDAY[2] radio call and stated “we’ve got engine failure”. Shortly after, the aircraft was observed in a descending left turn.

The aircraft initially contacted a power line and fence before coming to rest on a residential street against a parked car (Figure 1). The pilot was fatally injured and a post-impact fuel-fed fire destroyed the aircraft. There was also damage to a residential property and the parked car.

Figure 1: Accident site

Figure 1: Accident site of Cessna Aircraft C172S, registered VH-EWE, near Moorabbin Airport, Victoria

Source: ATSB

Aircraft information

The Cessna 172S aircraft was manufactured in 2006. It had 6,348 hours in service prior to the accident flight and was predominantly used for flight training. The aircraft was fitted with a Lycoming IO-360-L2A fuel injected engine and McCauley two-blade, fixed pitch propeller.

The maintenance carried out on EWE before the accident flight included a periodic inspection and scheduled engine change. A valid maintenance release had been issued just prior to the accident flight.

The installed engine had recently undergone a scheduled inspection and overhaul at another maintenance facility. As part of that process, the engine had been run on a test bed at the overhaul facility for about 2 hours. Post installation into EWE, it was reported that the engine was twice operated on the ground for a total of about 30 minutes.

Wreckage examination

On-site examination of the wreckage and surrounding ground markings indicated that the aircraft collided with terrain in a nose‑down attitude. The tail of the aircraft twisted clockwise as a result of the impact with the fence and was inverted. Evidence of the fire extended down the street, and was indicative of fuel being released with the rupturing of the fuel tanks.

The degree of propeller damage observed on-site was consistent with the engine not producing power at the time of impact. The engine, propeller and several other components were retained for further examination.

The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to be.

Engine and propeller examination

The engine and propeller were subsequently examined at an independent engine overhaul facility, under ATSB supervision. Representatives from the Civil Aviation Safety Authority, the aircraft maintenance organisation, the engine overhaul facility, and the aircraft insurer were present at the engine disassembly.

This examination did not identify evidence of a mechanical failure of the engine. Some additional components, including those associated with the fuel system, were retained for further examination.

Ongoing investigation

The investigation is continuing and will include consideration of the:

  • examination of retained aircraft and engine components
  • maintenance documentation
  • pilot’s experience
  • aircraft fuel records
  • audio analysis of engine sound (from ATC radio recordings)
  • available electronic data.

__________
The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this preliminary report. As such, no analysis or findings are included in this report.

__________

  1. Eastern Standard Time (EST): Coordinated Universal Time (UTC) + 10 hours.
  2. MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are being threatened by serious and/or imminent danger and the flight crew require immediate assistance.
General details
Date: 08 June 2018   Investigation status: Completed  
Time: 1713 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): near Moorabbin Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Collision with terrain  
Release date: 24 April 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 172S  
Aircraft registration VH-EWE  
Serial number 172S10361  
Type of operation Private  
Sector Piston  
Damage to aircraft Destroyed  
Departure point Moorabbin Airport, Victoria  
Destination Moorabbin Airport, Victoria  
Last update 24 April 2020